Over the last year, the general public has been inundated with a steady stream of reports about the dangers of opiates — pain medicines like codeine, Percocet, and OxyContin. The harm in terms of ruined lives and death from illicit drugs such as heroin is not news. But what is new, and concerning, are the risks of prescription pain medicines — those doctors prescribe for pain due to a range of causes, including musculoskeletal problems like low back pain.
The history of using opiates for chronic pain
Back pain isn't a new problem either, but the history of how doctors have treated it is probably new to many. A "cliff notes" version of what changed goes something like this. Studies showed that doctors weren't adequately treating the pain of people with advanced cancer. Research also showed that pain medicines such as opiates improved quality of life for these terminally ill patients. This realization led to recommendations that doctors monitor pain as they would any other vital sign (like temperature or blood pressure) for all their patients — and that all types of pain receive aggressive treatment, including long-term (chronic) pain, such as low back pain. At the same time, drug companies promoted new formulations of opioid medications with longer duration of activity that made it easier for patients to take on a regular basis.
The problem was that this fundamental change in practice was really devoid of any proof that it would help people better manage pain and minimize its effect on their lives. Prior reviews of the medical literature have documented that there is little evidence supporting the use of opiates for chronic low back pain. The modest benefits seen were with short-term use. The practice of using these medicines for long periods of time has not been carefully evaluated. Few risks were seen in these short-term studies, but tolerance to the effects of the medicine, side effects and dependence/addiction have become clearer with longer use.
A recent study published in JAMA Internal Medicine adds to this knowledge. Dr. Abdel Shaheed and colleagues performed an updated literature review, and their conclusions reinforce that only short-term benefits have been proven and the amount of that benefit is modest. Moreover, they examined the doses of pain medicines used in these studies and found that the pain relief people actually experienced was not that great.
Opiates for chronic low back pain carry big risks with uncertain benefits
This and prior studies clearly show that the leap to widespread use of opiates for non-cancer pain was premature. We didn't know the long-term benefits and risks. We still don't know the benefits, but this dramatic increase in use of pain medicines hasn't helped people return to their previous level of activity, and rates of disability haven't gone down. What is becoming clear are the risks, specifically rates of addiction, overdoses, and the rise of deaths attributed to prescription opiates. And people who have become addicted to their prescribed pain medicines often switch to heroin, which is cheaper and more readily available.
Now this doesn't mean that we should stop treating pain. For many, the pain is real, chronic, disabling, and they need help managing it. And it doesn't mean that everyone prescribed opiates becomes addicted. Nor does it suggest that opiate medicines have no benefits at all. But what it should do is give all of us pause. The bottom line is that simply taking a pill (or a handful of pills) doesn't fix low back pain — and can lead to a whole lot of trouble.
What you can do for back pain
Fortunately, there is growing evidence for treatments that can help with chronic low-back pain, but they aren't simple fixes in the form of pills, shots or surgery. Instead, treatments should focus on getting back pain sufferers active again and learning to manage, not cure, the pain. A range of therapies including exercise, education about how to care for your back, yoga, and mind-body techniques have been shown to help control back pain.
So what do I tell my patients? For those with chronic back pain who aren't on opiates, steer clear. For those who are already take them, you can't go cold turkey. Your body has adjusted to these medicines and stopping them abruptly is a bad idea. With help, people on opiate pain relievers can try to wean themselves off these medicines gradually and replace them with other treatments. This isn't easy, but for many people it starts a long process of regaining control over the pain that has taken over their lives and can help them avoid the terrible consequences of opiate addiction.